Evidence-Driven Quality Improvement, the Ascension Way

About 60 percent of these sets are based on Zynx order content, with modifications from clinicians. Approximately 40 percent are convenience-based work-flow enhancer based sets. The total library covers the major DRG conditions; many key acute care procedures, and those conditions most important to national quality initiatives (CAP, HF, MI, DVT, sepsis, surgical complications etc.) The order sets cover 199 total conditions that reach into many specialties and subspecialties.  However, there is still much to be done to meet specific practitioner needs.
 
In addition to covering multiple DRGs in the acute-care environment, we’re now moving into the ambulatory world as well. We work to ensure we include those elements of specific order sets that affect mortality, cost, length of stay, readmissions and quality indicators for the Affordable Care Act, the Deficit Reduction Act, all the other things the Centers for Medicare and Medicaid Services (CMS) [is focused; elements that have been associated with reimbursement in the new, emerging world of healthcare reform.  

Those particularly relevant items within the order set that have been shown by reviewed literature to affect mortality, cost, length of stay, and quality of care—are intentionally flagged for inclusion in order sets that may have been authored previously or independently by health ministries. Clinicians should be able to structure the order sets to meet their workflow and culture and they should contain the reportable key process indicators. It’s like establishing blue-ribbon items in the order sets, regardless of what may make them attractive to the clinicians. This is how we relate the order sets to our other key safety initiatives.

It is important to note, achieving safe and reliable, high-quality care is not simply a matter of having order sets. It is a matter of having programs and education while encouraging mind-set changes in practitioners in a host of very substantive ways.  That mindset should be reinforced with workflow compatible decision support tools for quality assurance wherever possible.
 
Philosophically, where do you strike the balance between standardization and customization?
 
There are a number of axes along which you can get standardization to occur. The most compelling in the clinical world is where you can create standardization around quality and safety. Another axis is around creating improved efficiency and/or reimbursement in the context of value-based purchasing or accountable care organizations. This an improvement in care transitions and best practice that is becoming a focus of enhanced reimbursement, despite the fact it has long been the ‘right thing to do’. Another axis is the IT axis. Standardizing infrastructure and system software brings economies of scale and interoperability along with outcome analytics and decision support feedback on health management at the point of care.
 
Do you think that that balance will be shaped fundamentally differently in different types of hospital organizations?
 
We face some unique challenges in our large and distributed leadership organization than more tightly integrated care model organizations (e.g. Kaiser, Geisinger, or IHC). Ascension Health can be considered a microcosm of healthcare providers across America beccause of our multiple systems and physician affiliation models. The drive toward standardization requires very different management skills and operating systems in this type of system. Responding to local market pressures, fulfillment of our Mission to meet the needs of those who are poor and vulnerable while focusing on infrastructure development as we continue to grow is one reason we seek quality processes and information convergence as unifying threads among multiple communities and styles of provider practice.
 
What have the biggest challenges in this area for you?
 
I think the biggest challenge we have had to face, as have our colleagues in healthcare, is the balance between standardization and autonomy.

What have been the biggest advances been in your organization in this area, the biggest triumphs so far?
 
Ascension Health has a terrific clinical information systems project management office that works in close conjunction with Clinical Excellence and oversees the progress of individual projects across the country; coordinating that is no small task. We work based on a clinical vision for HIT that is supported through integrated governance at multiple levels in our complex organization.

We are able to think and act in response to local cultures and pressures without losing sight of the need for independent standardization in many areas, one of which was the foundation set of clinical order-set content that Health Ministries can derive value as they develop their own clinical system work on their own timetable and according to their own culture. And our emphasis on unified approaches to measuring and tracking our many efforts is vital to quality and reliability management.

One built-in challenge is the diversity of your EHR vendor situation, correct?
 
That’s correct; approximately half of our Health Ministries are on a Cerner platform and those implementations are not completely common. In addition, we have Allscripts, Meditech, McKesson and several other EMR sites functioning.